To Do Radiation or Not do Radiation?

[Shorehousejam]

After a great response to the below treatments since diagnosis 07/01/2022

Triplicate Therapy including Docetaxel I qualified for a Swog Trial to have a Radical Prostatectomy with Extended Lymph Node Removal 

I decided against trial, since my hospital missed submission of paperwork.

So without the trial, I Had Davinci Radical Prostatectomy with Lymph Node Removal on 03/14/2023

Only 8 Lymph Nodes Removed, according to operating urologist surgeon that is what he saw to remove

The biopsy from 07/15/2023 when first diagnosed, the pathology report was sent to John Hopkins to Dr. Johnathan Epstein…

His pathology report was different on my Transperineal biopsy that I had done back last 07/15/2022 and upgraded to a Gleason 9 

Here is his summary compared to one in my bio

1. Prostate (Needle Core Biopsy, S22-28930, 7/15/2022) 4 out of 16 samples

:A. Small focus of prostatic adenocarcinoma, Gleason score 5+5=10 (Grade Group 5),involving less than 5% of one(1) core.

B. Prostatic adenocarcinoma, Gleason score 5+4=9 (Grade Group 5), discontinuously involving 100% of one (1) core.

E. Prostatic adenocarcinoma, Gleason score 5+5=10 (Grade Group 5), involving 30% of the total fragmented specimen.

K. Rare atypicalcells in a background of hemorrhage and scar. High-grade carcinoma cannot be excluded with certainty.

O. Prostatic adenocarcinoma, Gleason score 4+4=8 (Grade Group 4), involving two (2) cores (20%, <5%) with focal ductal features 

———-

Summary After Surgery:

John Hopkins Dr. Johnathan Epstein Pathology

Summary  Prostate and Pelvic Lymph Nodes

(Prostatectomy with Lymphadenectomy

Adenocarcinoma (conventional, NOS).

GLEASON SCORE, DOMINANT NODULE: 4+5=9

Grade Group 5

DOMINANT NODULE:

Left, lateral, posterolateral, posterior, base

Local EXTENT (8th Edition AJCC) Extraprostatic extension and extent of extraprostatic extension: Left, anterior, lateral, nonfocal (slide A17)

MARGINS: Positive Location and nature of positive margin:

Left, anterior, lateral and bladder neck

Positive in an area of extraprostatic extension (EPE),

Summed length of positive margin: >3 mm

Highest grade at margin: 5+5=10

Seminal VESICLE INVASION:None

Portion of right seminal vesicle present, negative for tumor

Lymphatic (SMALL VESSEL) INVASION: Absent

Pelvic LIYMPH NODES (including all parts):

Al 8 lymph nodes are negative for tumor. See note.

Metastatic prostatic adenocarcinoma involving soft tissue adjacent tolymph node (A23)

EXTENT OF INVASION

PRIMARY TUMOR:урТ3а: Extraprostatic extension or microscopic bladder neck invasion

Summary MARGINS:

Positive

Additional FINDINGS, UNINVOLVED PROSTATE:

Chemotherapy effect present with areas showing hemosiderin deposition and fibrosis present in benign prostatic tissue 

One (1) of Eight (8) lymph nodes shows treatment effect without viable tumor cells.

ADDENDUM: 5/3/23 Additional material received.

.1 Prostate (Needle Core Biopsy, S22-28930, 7/15/2022):

The pattern 4 ni this case lacks large cribriform morphology.

2. Prostate and Pelvic Lymph Nodes (Prostatectomy with Lymphadenectomy, S23-12074, 3/14/2023): The tumor shows focal ductal features.

The pattern 4 in this case lacks large cribriform morphology.

Arepresentativetumor block is A17 fi further molecular test is indicated.

Additional material (slides A1-A5, prostate base sections) was sent to us for review and confirmed bladder neck invasion and nonfocal extraprostatic extension, and positive margin (summed length ofpositive margin changed to 1 cm).

The original diagnosis andtumor staging remain unchanged.

Addendum electronically signed by Jonathan Epstein I, MD on 5/3/2023So

I spoke with Dr. Epstein his stated radiation would be next.

My two oncologist state no to radiation to prostate bed 

Another oncologist said absolutely yes to radiation 

However, one of my urologist said not yet due to incontinence  

Please help, my head is spinning I need some clarification as I’m so confused 

Thanks

[Tall_Allen]

Your PCa in your bones vastly overrides any consideration of cancer in your prostate bed and pelvic LNs. Your cancer has been debulked and that is the best you can do. Radiation on top of recently cut tissue is destructive, and there is no known benefit. I assume you are still taking ADT+abiraterone, which is beneficial.

[Shorehousejam in reply to Tall_Allen]

Yes I’m still on…Firmagon every 28 days and daily zytiga and prednisone

I’m still quite confused

I have 3 Lytic lesions that mainly dissolved is that considered Oligio Metastatic?

Another question, would radiation be better on prostate bed to delay reoccurrence? after I heal up since it’s been only 3 months,

Or do I have radiation after reoccurrence to bring PSA down?

[Tall_Allen in reply to Shorehousejam]

Yes,that is oligometastatic, which is why debulking the prostate made sense.

Your decision on debulking was prostatectomy or radiation, not prostatectomy and radiation. You chose prostatectomy. There is no known benefit to salvage radiation now that your cancer is in your bones. The only known beneficial therapy is systemic (hormones, chemo, etc.).

[Shorehousejam in reply to Tall_Allen]

Thank you

[Shorehousejam in reply to Tall_Allen]

So much information to retain

[Tall_Allen in reply to Shorehousejam]

Prostate cancer spreads outside the prostate via blood, lymph or nerves. If the metastases disappeared when you took hormone therapy, they were prostate cancer,

[Shorehousejam in reply to Tall_Allen]

Ok, Thank you

[Shorehousejam in reply to Tall_Allen]

I think it is bazaar to not radiate the prostate bed fossia, the nodes and any bone metastasis. Is that standard of care? or a trial that showed no benefit to All men? I’m confused as to where you got your knowledge on radiation being pointless

[Tall_Allen in reply to Shorehousejam]

I don't understand your situation with bone mets. You wrote that you had lytic bone mets but then you claim they weren't - which is it? It is important to know to make this decision. If you have had bone mets, there is no evidence that such action will be beneficial. I'm not saying there is evidence of no benefit, I'm saying there is no evidence of benefit - see the difference? . But there is a good chance that it will result in side effects. If you have not had bone metastases, a wider field of radiation may be curative. So you have to be sure about it first and make your decision from there.

[Shorehousejam in reply to Tall_Allen]

I have 3 lytic bone Mets in my pelvic bone area, resolved I guess by Docetaxel and ADT

I have possibly one lymph node that may be active, I have to ask about the scan if I’m reading it right

[Tall_Allen]

So the bone metastases were biopsied? How else would anyone know they were negative for adenocarcinoma?

If they were not metastases, you can still treat your pelvic LNs. You will have to wait for tissues to heal from your prostatectomy. Probably 7 months would be good.

[Shorehousejam in reply to Tall_Allen]

From looking at all the lymph nodes removed , the bone lytic lesions 3, we assume because of pet scan

[Tall_Allen in reply to Shorehousejam]

Your doctors think that because the bone metastases did not express PSMA that they were not adenocarcinoma?

[Shorehousejam in reply to Tall_Allen]

I have a question on the addendum of my pathology report my margins were changed from 1mm to 1cm, see here:

Additional material (slides A1-A5, prostate base sections) was sent to us for review and confirmed bladder neck invasion and nonfocal extraprostatic extension, and positive margin (summed length of positive margin changed to 1 cm).

That’s 10mm isn’t that insanely large margin? Wouldn’t the surgeon notice this and take more? What am I missing here?

[Tall_Allen in reply to Shorehousejam]

If he takes the entire bladder neck, you have permanent incontinence. If you wanted a larger margin treated, radiation, not surgery does that.

[Shorehousejam in reply to Tall_Allen]

ok so 1cm is the total of all EPE? Not all the way around…this I’m getting from the addendum on my pathology report below:

Additional material (slides A1-A5, prostate base sections) was sent to us for review and confirmed bladder neck invasion and nonfocal extraprostatic extension, and positive margin (summed length ofpositive margin changed to 1 cm

[Tall_Allen in reply to Shorehousejam]

It is not small - that is all that matters.

[CAMPSOUPS in reply to Shorehousejam]

Tall Allen had a important question regarding whether you really have lytic lesions or not: Your doctors think that because the bone metastases did not express PSMA that they were not adenocarcinoma?

I dont want to put words in his mouth but I think he is saying lytic lesions cant be confirmed by lack of PSMA expression. And more than likely the only confirmation comes from bone biopsy.

[Shorehousejam in reply to CAMPSOUPS]

yes I am oligo metastatic

[CAMPSOUPS in reply to Shorehousejam]

Right. I'm just confused or wondering if you actually have confirmation of the rare Lytic bone lesions instead of the Osteoblastic bone lesions which are more common.

[Shorehousejam in reply to CAMPSOUPS]

yes from a pet scan…no bone Biospy

[Mrtroxely]

HiI had 5(was going to be 6) radiotherapy sessions to prostate.

No real side effects as yet.

Tiredness occasionally.

Weird pain at begining of urination.

All manageable and much less than feared.

All is still working down there.

My thoughts on having radio.

1.

People who have prostate removed can and do regularly get issues and spread.

If that happen then options remain same with radio being the main treatment.

It works more than not.

2. If mets turn up in spine I'd probably plead for radiotherapy to the met....

3. For me, I believe it did more than chemo to reduce my PSA.....?????just my thoughts

4.

What else is there.....

[slpdvmmd]

The bone issue is confusing to me. Lytic bone metastasis in prostate cancer is rare as most are osteoblastic i.e. making bone. For local control pelvic radiation seems reasonable. If in fact the bone lesions are prostate cancer proven by biopsy then I would say the treatment of oligometastatic prostate cancer is evolving and some centers would treat your isolated bone mets.

[Shorehousejam in reply to slpdvmmd]

Thank you, my wife and I find, that we really have to push these physicians to do what we want, not want they constantly repeat as if reading from a Standard of Care manual…good grief

[slpdvmmd in reply to Shorehousejam]

Getting cutting edge care rather than cook book care is a constant struggle. You have to read a lot and really work at educating yourself. I wish you well in this struggle.

[Shorehousejam in reply to slpdvmmd]

Thank you and the Best to You

[RMontana]

Wow, a lot to unpack. First, this caught my eye;

Your Post; "Rare atypical cells in a background of hemorrhage and scar. High-grade carcinoma cannot be excluded with certainty."

Have you considered, obtained or thinking about Germline and Genomic Testing. What I read is that either FH (family history) or rare/ a-typical/ unusual tumor or cell structures require both! These tests could reveal a treatment tailored to the a-typical condition found in your genetic or tumor cellular make up. Check these references;

See between Min 44:32 thru 46:52; healthunlocked.com/active-s...

healthunlocked.com/active-s...

healthunlocked.com/active-s...

As far as sRT (salvage radiation) on top of RP (prostatectomy) that is what I had. My PSA was recurrent at 6 weeks post op and I had sRT to the fosa, bladder neck (I had neck invasion as well), plus the pelvic lymph nodes (I had 11 nodes removed). What I read is that there is definite benefit to sRT either adjuvant (no recurrence of PSA) or as early salvage...check out these references;

healthunlocked.com/active-s...

healthunlocked.com/active-s...

...but sRT can cause Continence issues; it did with me. I was not dry-dry (100% dry) when I went into sRT and that condition was locked in place. I will leak 'for the duration,' but I went ahead w the sRT at the time knowing this. Check these links out;

healthunlocked.com/active-s...

healthunlocked.com/active-s...

Your pathology is different than mine (GS 4+3); GS 5 is spread by blood so you need to act with some urgency. But take some time to understand what the impacts of your decisions will be. Dont rely, expect or depend on your Dr's to tell you what these consequences will be...in my case I had to find out why a consequence happened and THEN react to it. But do your best, make a decision, then dont look back and roll with the punches. Let us know what happens...Rick

[Shorehousejam in reply to RMontana]

I’m on ADT triplicate therapy as I am olgio metastatic,

Thank you for all that great information

[StephH72 in reply to RMontana]

thank you RMontana for this detailed reply. I sent you a message with a question. And Shorehousejam thank you for asking this question. I hope you discover the best path forward through this very confusing journey.

[Shorehousejam in reply to RMontana]

Rick 4 is not spread by blood but 5 is?

[RMontana in reply to Shorehousejam]

Yes, this is what I have read and what my URO stated to me. I had 'Pattern 5 at the EPE,' which is stating there was some differentiation of my PCa cells at the margin! For that reason and the fact that I had a whopping 0.97 out of 1.0 score on Decipher I was considered Intermediate-High Risk. I proceeded with sRT (salvage) and did 15 months extra ADT, on top of 6 months prior to sRT, for a total of 21 months. Here is a study that determined that the combined percent of pattern 4-5 in the pathology sample was a better predictor of progression than the GS...check this out.

healthunlocked.com/active-s...

If you do proceed with sRT and the issue of concern is MET outside the fossa area then this study states its important to get PSA readings before, during and after sRT treatment! I did on my own and I am glad I did...most doctors will not do this unless you ask them...check this out.

healthunlocked.com/active-s...

If you are concerned about sRT before you are dry then this study may be of interest (if I have not shared it already). I was not 100% dry at start of sRT and I will remain this way for the rest of my life...but I did not want to wait and NO ONE would tell me that my PCa would not spread while on ADT...that it would 'slow down,' 'stop growing,' yes, but that it would not spread by blood no...so I did not wait beyond 6 months. But 67% of men go into sRT with Grade 1 leakage, which is Dry or with a 'Safety Pad,' which means that they are still leaking..check this out.

healthunlocked.com/active-s...

I am comfortable that for high risk PCa patients sRT and ADT have a positive effect. I have provided the references for this; let me know if you need them again. I also see some comments on this portal state that there is no benefit from sRT after a RP but I dont see the studies that back that up. Here is another not shared previously that supports sRT (actually adjuvant) radiation post RP...check this out; it also talks about patients with pattern 5 and the need for RT post RP...go to Min 21:14 for the explanation of the 'adjuvant gap,' which means, the possible undertreatment of 25-30% of cases that could benefit from radiation;

youtu.be/oWNKPhUjCXc(Not working as expected?)

Good luck. Rick

[Shorehousejam in reply to RMontana]

Thank you for sharing your research and for this very explansive reply, my wife and I are grateful to you